Saturday, June 25, 2011

Something to Celebrate: Young People to be Proud Of

So those of you who follow me on Facebook and Twitter might have noticed that I've recently become infactuated with the work done by a local group called the United Teen Equality Center. They are a youth-led coalition which works toward empowering young people to create change through policy-making.

The group provides a great antidote for those who think that young people are unengaged, uninterested, and, well, unlovable. I often hear so much hate directed toward young people--particularly young people from our urban cities.

Right now the organization is working on getting state bill #S00183 passed in Massachusetts. The bill would require state education officials to develop a high school civics course that covers the various branches of local, state, and federal government. The course would also teach high school students the history of social movements as well as current events. It sounds like a pretty good idea to me--teaching young people to be engaged in their community and government.

I've known for a long time the power teens have. In the early 90s I works at a youth shelter for teens who have runaway from home or were thrown-away by their parents. Some of those young people were the most engaging, hopeful, and intelligent people I've ever met. I think when I encounter the United Teen Equality Center and their work, I remember the young faces of the teens at the shelter I worked at. I remember the potential that was lost and found in the people who came through that door.

I hope you learn to see that potential, too.

Friday, June 24, 2011

Patient Suicide: Part One--The Phone Call

This is part of an ongoing story about a patient suicide. Click here for Patient Suicide Part One: The Phone Call, here for Patient Suicide Part Two: 30 Minutes to Think, here for Patient Suicide Part Three: Fully Present, here for Patient Suicide Part Four: What's a Life Worth, here for Patient Suicide Part Five: Treat People Like They Matter, here for Patient Suicide Part Six--Leftovers, here for Patient Suicide: Part Seven--Training Monkeys/Herding Cats, and here for Patient Suicide: Part Eight--On Scarves and Lessons Learned

With some well trained and carefully manicured hubris in place, it was a phone call that I thought could never happen to me. I've had 12 years of post-secondary education, over 10,000 hours of supervised clinical practice with some of the most brilliant psychologists in the country, and more than two decades of work experience. Arrogance and hubris, right? Denial, too. I knew this phone call would come some day. I just hoped I'd make it a little longer.

In the months since I've received the phone call, I've struggled with whether I should speak openly about the call. I've convinced myself every way I know how that I shouldn't write this. Psychologists do not violate the privacy and dignity of their patients. Yes, that's right. However the phone call isn't really about a patient. It's about a psychologist's response. I can't find protection from this topic behind the veil of confidentiality.

Psychologists don't self-disclose. That one almost got me. One wouldn't want to share thoughts or experiences that are too deeply personal or too deeply private. Psychologists just don't do that. It might contaminate my work with patients. This of course is just poppycock. Therapists engage in self-disclosure. Our choices in office decor, clothing, attitude toward therapy--all are forms of self disclosure. Psychologists are masters at self-disclosing for a purpose. We are not--and cannot--be an invisible blank screen. We always are disclosing something--the question is are we aware of what we are sharing and aware of the reasons we are sharing.

Fine then. I cannot hide behind confidentiality or arbitrary rules about self-disclosure. Maybe I just don't want to share. That's a perfectly good reason. Right? Well yes it is. Of course I can always decided to keep something private if I want to. Of course. But why, why do I want to keep it private?

It became clear to me today that the only reason I've not yet written this is fear. Fear of judgement. Fear of being viewed as a failure. Fear of finding out that I indeed, actually did fail. Fear. That's not a very good reason to stay silent.

It's likely that if I'm having this experience, there are many others who are having this experience. Who am I to disagree with Irv Yalom when he says "the recognition of shared experiences and feelings among group members and that these may be widespread or universal human concerns, serves to remove a group member's sense of isolation, validate their experiences, and raise self-esteem."

Fine Irv. I was almost able to resist you and your logic, and then Marsha Linehan had to chime in. I read an article today from the New York Times in which Dr. Linehan disclosed her personal sturggle with mental illness. She said "so many people have begged me to come forward, and I just though--well, I have to do this. I owe it to them. I cannot die a coward."

So really. What's a psychologist to do? Ignore Irv's observation about the curative power of bringing a universal experience into the public eye? Ignore Marsha (as if one could do that) and die a coward?

So I write.

It was late in the afternoon when my phone rang. I already knew what the message was.

Never early, never late, I would open up the door when the church bells behind my office rang marking the new hour and find my patient walking in the door. The day my phone rang my patient wasn't there. "Strange", I thought. She never missed an appointment. She was never late, never early. I knew there was something wrong well before the phone ever rang.

While I was busy telling myself that there was clearly going to be some sort of funny explanation for her no-show, on a deeper level I started preparing for the storm that was to come. While I wasn't emotionally ready, I did exactly what I was trained to do.

I waited for 15 minutes and then called my patient. As I rule, I never call patients the day they miss an appointment. This time I made the call. I knew the risks facts for this patient. I knew the signs. I knew just what to do. I called my patient. No answer on her mobile. No answer at home.

Still not fully aware of the storm I was preparing for, I went into crisis mode. I knew with urgency that I needed to start taking increasingly more aggressive steps to contact my patient. On a deep level, I knew what I was going to find out.

A storm was coming. Be prepared. It was like a well choreographed dance. I left messages, and gave a deadline.

"I'm worried," I said into the voice mail.

"You're never late, you're never not here."

"Please call me as soon as you get this. If I don't hear from you in an hour I'm going to contact your friend. If your friend hasn't heard from you I'll have the police come to your house to do a wellness check. If the police can't find you and tell me that you are okay I'll have no choice but to fill out papers to have you involuntary hospitalized. Please call. I'm worried."
For those of you who aren't therapists or are therapists who are still in training, you should know that in the jurisdiction in which I'm licensed, if I'm concerned about the safety of a patient I have a range of options available to me. The least invasive is a wellness check. A psychologist, or concerned person, can contact local law enforcement, explain the situation, and ask for a wellness check to be done. When I feel a patient is in imminent danger, I am allowed by law to loosen the laws of confidentially in the service of protecting my patient--this is why I felt comfortable with the plan of contacting the best friend of my patient and then contacting the police. The key here is that once I signal to the outside world that I'm concerned about a patient's safety (e.g., contacting a friend, doing a wellness check) I have to keep working and finding and assuring that patient is safe until I either exhaust all reasonable options, get the patient to safety, or otherwise feel sure that the patient is safe.

My patient's appointment time came and went. My next patient came, and that hour ended too.

"I'll check my voice mail", I thought. Surely my patient will have called by now. Right? I entered my password to get into my voice mail. One new message. Good. Something must have happened. She called. She'll feel guilty she missed her appointment. We'll talk about that. We'll move on.

The phone call came. The one I always knew I would get. The one I hoped I would never get.

"Hi Dr. Mihalko," the strained strangers voice said. "This is so-and-so, a friend of your patient so-and-so." She used xxxx over the weekend to kill herself. She left a note. The one thing she asked me to do was to call you and tell you what happened."

The phone call had come.

A patient had died.

I felt like I had been slapped.

I sat down in the chair my patient had always sat on. My dog came to me, wagging her tail, looking up to me as if to say she knew. We both knew before the phone call came.

"I must have heard this wrong," I told Maggie the therapy dog. "I think she said so and so tried to kill herself, and that she is in the hospital." I listened to the message again. I must have missed the part where I was told what hospital she was in. I'd call her psychiatrist, call the hospital, and maybe arrange to visit.

I listened to the message again. Nope. It was the call. My patient wasn't in the hospital. She was dead.

"No no no Maggie," I said again. I'm not hearing this right. I listened to the message a third, fourth, and finally a fifth time before I alternated between laughing and cursing at Elizabeth Kubler Ross. Damn her for being right that the first stage of grief is denial.

The phone call that I always knew would come had arrived. That call I always hoped would not happen had finally happened. Twelve years of post-secondary education, more than 10,000 hours of supervised clinical experience, twenty years of experience in a variety of counseling settings... All those experiences brought me this single point in time.

I reached the absolute limit of my training.

I had state-of-the art training in the assessment, management, treatment, and prevention of suicide.

No one ever told me what to do after the phone rang.


So I write. This is part one. There will be more parts. I don't yet know how many parts I will write. I don't know over how long of a span of time I will write about this. I will write. That I know.

I write because I have learned that psychologists and other therapists don't want to talk about this. There is a secret club of clinician survivors of suicide. Many of us are hidden. Some are silent because they are afraid of what people might say. Other's stay silent because no one will listen. Many will avoid us because they are afraid of what will happen when their phone rings some day.

There are lots of you out there who aren't clinicians who are also in this club of suicide survivors. I'm writing for you too.

I write for those of us who have already received the call and are struggling to make sense of it. I write for those who have not yet received their call.

 I hope these words give you a guide. 

Sunday, June 12, 2011

Middle School Lunch Room, Take Two: Build Relationships, Don't Destroy Them

Yesterday I wrote a blog piece talking about the general dismal state of political discourse. A day doesn't go by without at least one public mention of an "us versus them" statement that breaks relationships rather than builds relationships. I've been squirreled away at home most of this weekend reading various original narratives about nonviolence. This quote is yet another to serve as a good reminder of the importance of building relationships and unifying people. So much of our discourse (any side of the political spectrum, and topic) is locked in an us versus them mentality. Let this serve as a call to action

And so I plead with you this afternoon as we go ahead: remain committed to nonviolence. Our aim must never be to defeat or humiliate the white man, but to win his friendship and understanding. We must come to see that the end we seek is a society at peace with itself, a society that can live with its conscience. And that will be a day not of the white man, not of the black man. That will be the day of man as man. 
--Martin Luther King, Jr.
--Our God is Marching on!
--March 25, 1965
Montgomery Alabama

The next time you find yourself in a polarized discussion and locked in a battle to determine who's right, think of this quote. How might you chart another way and build relationships rather than destroy them. When you hear our political leaders speaking relationship destroying words, think for a moment on how they  might do it another way.

Freedom's Just Another Word for Nothing Left to Do?

I'm watching the CBS Sunday Morning Show. I'm finding that I can't look away from the segment called "Don't Try This at Home." The segment started with roller derby girls running across a track while they  are on fire. They are chronicling a dare devil spectacular in Omaha Nebraska.

The star of the show is  Spanky Spangler. One of the last scenes in the segment involved a car drop. Spanky was suspended by a crane 190 feet in the air. He is dangled for a moment in a car and then dropped, head first, into a pile of vans.

After his drop Spanky said, "When you are an American dare devil it is a sign of of freedom. We are lucky to live in a country like this where you have freedom. Being a daredevil doing what you want to do, no matter how dangerous it is is freedom, it's freedom."

I'm all for a little thrill seeking. I've been known to do a little of it myself (though never have I intentionally set myself on fire nor have I been dropped from a crane in a car). That's not what I take issue with this morning.

Being a dare devil is a sign of freedom? Yes. Sure. In a superficial way having the freedom to run around whilst on fire or being dropped into a pile of cars is a sign of freedom. But is that the kind of freedom we want to celebrate. Is that how we want to spend our freedom?

Over the last couple of days I've been reading some of the major speeches that Martin Luther King, Jr. gave during his lifetime. In his Letter from Birmingham Jail, written on April 16, 1963, he wrote:

But though I was initially disappointed at being categorized as an extremist, as I continued to think about the matter, I gradually gained a measure of satisfaction from the label. Was not Jesus an extremist for love: "Love your enemies, bless them that curse you, do good them that hate you, and pray for them which despitefully use you, and persecute you." Was not Amos an extremist for justice: "Let justice roll down like waters and righteousness like an ever-flow stream." Was not Paul an extremist for the Christian gospel: "I bear in my body the marks of the Lord Jesus." Was not Martin Luther an extremist: "Here I stand; I cannot do otherwise, so help me God," And John Bunyan: "I will stay in jail to the end of my days before I make a butchery of my conscience." And Abraham Lincoln: "This nation cannot survive half slave and half free," And Thomas Jefferson: "We hold these truths to be self-evident, that all men are created equal..." so the question is not whether we will be extremists, but what kind of extremists we will be. Will we be extremists for hate or for love? will we be extremists for the preservation of injustice or for the extension of justice? ...perhaps the South, the nation and the world are in dire need of creative extremists.

Here MLK was talking about extremism, not freedom. The underlying concept is the same. What kind of freedom do we want to have? It's nice (I suppose) to do any number of different dangerous acts. We have a choices that many in this world do not have. How do we want to use that choice? Do we want to use that choice for sensation seeking? Personal gain? How about the betterment of humanity? Making something better for those who come after us?

You have the freedom to choose.

Saturday, June 11, 2011

Debt Increases Self Esteem?

Everywhere I've turned recently I've been seeing the headline flashed at me. I've seen it running on the treadmill at the gym, I heard it on the radio, and it's all over Twitter.

 "Debt increases self esteem."

It seems that some folks at Ohio State University crunched some numbers and found out that at least in younger adults, holding debt actually increases self esteem. Here are two things from the study:

They looked at how... debt [was] related to people's self-esteem and sense of mastery--their belief that they were in control of their life, and that they had the ability to achieve their goals. 
Results showed that those in the bottom 25 percent in total family income got the largest boost from holding debt--the more debt they held, both education and credit card, the bigger the positive impact on their self-esteem and mastery.

Reading this article got me thinking about some of my early experiences working in community mental health. It didn't matter how impoverished my clients were, I always knew they would have a pager, call waiting, and cable television (back in the day, these were all the rage!). I always wondered why I'd be working with families that would go hungry at times but never give up call waiting. It just didn't make sense to me.

A supervisor at the time scolding me for being judgmental and not very understanding of the perspective of my clients. She explained the importance of status symbols. People who have very little will often use what they have to get the things that are associated with feeling good or feeling important. "We live in a world that we make ourselves feel better with things," my supervisor explained. "You're job, if you are up to it, is find a way to help your clients feel better in other ways."

She also pointed out who I had all the cool things (indeed, I had a pager (and needed a supply of quarters so I could use the nearest payphone when someone "important" called me), I had a Sega video game system, cable tv, and call waiting. Wasn't I important? At least, didn't I surround myself with things that were associated with being important.

I wish these researchers from OSU had looked at the qualitative nature of the group they were studying. Just why did that bottom 25% feel the most self esteem from their debt? Have they collected the most of whatever the modern day feel good gadgets area?

More importantly, can we talk about how we can feel better in ways that don't involve consumption or ownership of things?

Bygone Days: Whatever Happened to Nonviolence?

Have you ever wondered what ever happened to public dialogue that lifts rather than depresses? Were you aware of the moment in time when attempts for connection and mutuality denigrated into fights reminiscent of middle school lunch rooms?

I think about this a lot.

The conversation always goes something like this.

 "What you are thinking and feeling is wrong. It's going to be the downfall of society if you keep thinking and feeling that way. You need to think my way. It's better than your way."

"Oh yeah?" says the other person. "Well let me tell you all the ways in which your thinking and feelings are wrong. Mine are actually right, and if we keep on going down the path you are going on we are all going to be doomed."

"You are so wrong! I'm better than you. Don't you get it?"

"You just don't get it. I can't believe how frustrating you are. Why can't you just listen to me?"

It starts to all feel a little bit like this commercial, only not nearly as cute.

What does this accomplish? Both sides of any dichotomy are entrenched in any number of value based viewpoints of the world. Those values are important to the speaker and appealing to their intellect to see it another way isn't like to help. After all, they are trying to appeal to your intellect to see it another way. Are you listening or changing your mind?

What can one do? Our not so distant history is replete with examples of another way -- a nonviolent way. In his 1964 Nobel Prize Acceptance Speech, Martin Luther King Jr. said

Civilization and violence are antithetical concepts. Negroes of the United States, following the people of India, have demonstrated that nonviolence is not sterile passivity, but a powerful moral force which makes for social transformation. Sooner or later all the people of the world will have to discover a way to live together in peace, and thereby transform this pending cosmic elegy into a creative psalm of brotherhood. 
If this is to be achieved, man must evolve for all human conflict a method which rejects revenge, aggression and retaliation. The foundation of such a method is love.

So how exactly is a conservative Christian to set aside rejection and love someone who is a gay activist? How is a political liberal to set aside revenge against a political conservative (or vise-versa). Clearly conversations that sound something like a middle school lunch room conversation aren't going to help us rise up and transform ourselves from this mess.

Might the non-violent movement of the sixties and seventies offer us some answers? Might they offer a way for any individual to clearly show the travesties inflicted upon them without reducing themselves to inflicting travesties upon another?

I think so. Do you?

A few last thoughts from Martin Luther King's acceptance speech in Oslo.

I accept this award today with an abiding faith in America and an audacious faith in the future of mankind. I refuse to accept despair as the final response to the ambiguities of history. I refuse to accept the idea that the "isness" of man's present nature makes him orally incapable of reaching up for the eternal "oughtness" that forever confronts him. 
I refuse to accept the idea that man is mere flotsam and jetsom in the river of life unable to influence the unfolding events which surround him. I refuse to accept the view that mankind is so tragically bound to the starless midnight of racism and war that the bright daybreak of peace and brotherhood can never become a reality. 
I refuse to accept the cynical notion that nation after nation must spiral down a militaristic stairway into the hell of thermonuclear destruction. I believe that unarmed truth and unconditional love will have the final word in reality. This is why right temporarily defeated is strong than evil triumphant.

What do you refuse to accept? Perhaps if just one of you walked the nonviolent path with a friend, they would be encouraged to do the same. They  might walk that same path with two of their friends, and so on, and so on, and so on...

Wednesday, June 8, 2011

Health Care Reform

I was reading the Globe this morning and came across an article about the Lahey Clinic exploring a merger with Beth Israel.  I have no comment about the hospitals merging. I do have a brief comment (also known as a rant) about one particular quote in the article.

Doctors and hospitals also will be forced to take on more financial risk. If they run over budget in caring for a patient, they can lose money; if they come in under budget, they can turn a profit.

It's nothing new that at for-profit hospitals, the bottom line is making a profit. It concerns me though that at the very basic level of insurance reimbursement, there is going to be another built in pressure whereby medical decisions are driven (in part, at least) by a concern for a profit. As a people, we are prone to making decisions in the short term to safe money that in the long term are devastatingly expensive.

Some insurance companies have become so broken as companies that they are nearly non-functional. These non-functional corporate entities are going to be driving health care decisions? Really?

Let's not be penny wise and pound foolish.